Provider Demographics
NPI:1699713644
Name:SIVAKUMAR, PREETHI NIMALKA (MD)
Entity type:Individual
Prefix:DR
First Name:PREETHI
Middle Name:NIMALKA
Last Name:SIVAKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 N 92ND ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4534
Mailing Address - Country:US
Mailing Address - Phone:480-314-1033
Mailing Address - Fax:
Practice Address - Street 1:10200 N 92ND ST
Practice Address - Street 2:STE 102
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4534
Practice Address - Country:US
Practice Address - Phone:480-314-1020
Practice Address - Fax:480-314-1019
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25656174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ414128Medicaid
AZ414128Medicaid
AZ104904Medicare ID - Type Unspecified